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PERSONAL DETAILS MEMBER TYPE Active Member: Help fight fires. Complete all sections excluding section 6. Non-active Member: Member with residential properties. Not fighting fires. Complete Sections 1 and 5. Corporate Member: Member with business property/ Agricultural holdings/ rural property/ government institution. Not fighting fires. Complete sections 1, 5 and 6. MEMBER/APPLICANT DETAILS SECTION 1 Full Name (required) Surname (required) Preferred Name (required) Birth Date (DD/MM/YY) ID Number (required) Age (required) Marital Status Gender Home Language Second Language Cellphone Number Email Address Home Tel Number Work Tel Number Home Address & Postal Code MEMBER EMPLOYMENT DETAILS SECTION 2 Occupation/Nature of Business Employer Employer’s Registered Name with the Compensations Commissioner Employer’s Registered Number with the Compensations Commissioner Employers Address & Postal Code MEMBER'S MEDICAL DETAILS SECTION 3 Doctor's Name Dr Contact No Medical Aid Medical Aid Number Main Member Member's Ref Number Main Member ID Benefit Option Member's Blood Type Allergies MEDICAL BACKGROUND SECTION 4 Does the member suffer from any Chronic medical condition? (required) Is the member receiving any medical treatment for a condition? Has the member received any operations or medical procedures in the last 6 months? Does or has the member suffered from any disabilities? Does the member have any special needs/ prosthetic limbs/ hearing aids? Qualified Medic/Paramedic? Qualified Fire Fighter? Please specify any other medical information NEXT OF KIN/EMERGENCY CONTACT 1 SECTION 5 Full Name Surname Preferred Name Relationship Living With Member? Cellphone Number Home Number Work Number Home Address NEXT OF KIN/EMERGENCY CONTACT 2 SECTION 5 Full Name Surname Preferred Name Relationship Living With Member? Cellphone Number Home Number Work Number Home Address CORPORATE MEMBER DETAILS SECTION 6 Corporate Member Type Size of Property in m² Business Activity Name of Business Type of Business Registered Name of Entity Registered Number Physical Address Cellphone Number Home Tel Number Work Tel Number Email Address ID|Passport Copy Approval of Corporate membership is subject to inspection by SBBV management. All personal and medical details are kept confidential as specified by the POPI Act. Information will only be shared with the correct parties in case of an emergency where needed.

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